Clinic Forms
New health care plans are needed at the beginning of every school year.
Please click FORMS LINK to access all health forms.
If your student has a health condition that may require additional care while in school, you will need to fill out an Action Care Plan Form for that condition. This will need to be done every year. If medication needs to be kept at school for your students, please fill out the medication administration form. Attached to each of these conditions is the required action plan and medication forms that will need to be provided to the school for your student. If you have any further questions or concerns, please contact your school nurse.
Asthma
Asthma Action Plan (requires a doctor's signature): Asthma Action Plan Forms
Request to Administer Medication: Request to Administer Medication Form
A separate form is needed for each medication, (if medication is to be given daily for longer than 2 weeks, it requires a doctor's signature).
Permission to Carry Emergency Medication (requires a doctor's signature): Student Permission To Carry Approved Medication Form (English) (Spanish)
Allergies: Food, Insects or other allergens your student could come in contact with while at school.
Allergy Food/Insect Action Plan (requires a doctor's signature): Food/Insect Allergy Health Action Plan Forms (English) (Spanish)
Request to Administer Medication: Request to Administer Medication Form
A separate form is needed for each medication, (if medication is to be given daily for longer than 2 weeks, it requires a doctor's signature).
Permission to Carry Emergency Medication (requires a doctor's signature): Student Permission To Carry Approved Medication Form
Diabetes
Diabetes Action Plan (requires a doctor's signature):Diabetes Health Action Plan Forms
Request to Administer Medication: Request to Administer Medication Form
A seperate form is needed for each medication, (if medication is to be given daily for longer than 2 weeks, it requires a doctor's signature).
Permission to Carry Emergency Medication (requires a doctor's signature): Student Permission To Carry Approved Medication Form
Seizures
Seizure Action Plan (requires a doctor's signature): Seizure Health Action Plan Forms
Request to Administer Medication: Request to Administer Medication Form
A seperate form is needed for each medication, (if medication is to be given daily for longer than 2 weeks, it requires a doctor's signature).
Permission to Carry Emergency Medication (requires a doctor's signature): Student Permission To Carry Approved Medication Form
Other Health Conditions
General Health Plan Note Listed Above (requires a doctor's signature): Individualized General Health Action Plan Form
Permission to Perform Specialized Medical Care in School: (Examples: Feeding through a feeding tube, administering oxygen, tracheostomy care, urinary catheterization, etc.)
Specialized Health Care Permission (requires a doctor's signature): Permission to Perform Specialized Medical Care in School Form